Articles tagged as "Asia"

Pooled ribonucleic acid testing to maximize detection of acute HIV infection

Impact of nucleic acid testing relative to antigen/antibody combination immunoassay on the detection of acute HIV infection.

De Souza MS, Phanuphak N, Pinyakorn S, Trichavaroj R, Pattanachaiwit S, Chomchey N, Fletcher JL, Kroon ED, Michael NL, Phanuphak P, Kim JH, Ananworanich J, RV254SEARCH 010 Study Group. AIDS. 2015 Apr 24;29(7):793-800. doi: 10.1097/QAD.0000000000000616.

Objective: To assess the addition of HIV nucleic acid testing (NAT) to fourth-generation (4thG) HIV antigen/antibody combination immunoassay in improving detection of acute HIV infection (AHI).

Methods: Participants attending a major voluntary counseling and testing site in Thailand were screened for AHI using 4thG HIV antigen/antibody immunoassay and sequential less sensitive HIV antibody immunoassay. Samples nonreactive by 4thG antigen/antibody immunoassay were further screened using pooled NAT to identify additional AHI. HIV infection status was verified following enrollment into an AHI study with follow-up visits and additional diagnostic tests.

Results: Among 74 334 clients screened for HIV infection, HIV prevalence was 10.9% and the overall incidence of AHI (N = 112) was 2.2 per 100 person-years. The inclusion of pooled NAT in the testing algorithm increased the number of acutely infected patients detected, from 81 to 112 (38%), relative to 4thG HIV antigen/antibody immunoassay. Follow-up testing within 5 days of screening marginally improved the 4thG immunoassay detection rate (26%). The median CD4 T-cell count at the enrollment visit was 353 cells/µL and HIV plasma viral load was 598 289 copies/ml.

Conclusion: The incorporation of pooled NAT into the HIV testing algorithm in high-risk populations may be beneficial in the long term. The addition of pooled NAT testing resulted in an increase in screening costs of 22% to identify AHI: from $8.33 per screened patient to $10.16. Risk factors of the testing population should be considered prior to NAT implementation given the additional testing complexity and costs.

Abstract access

Editor’s notes: Acute HIV infection (AHI) is generally defined as the time between HIV acquisition and the appearance of detectable antibodies. Individuals with AHI are highly infectious, at least partly due to high viral load. Effective strategies to identify people with AHI could therefore plausibly reduce transmission, although the extent to which AHI drives transmission at a population level continues to be debated. Although the fourth generation immunoassays, incorporating detection of p24 antigen, have been shown to detect infection earlier, there is still a period during which only HIV ribonucleic acid (RNA) can be detected. High costs limit the routine use of HIV RNA testing for this purpose. Pooling samples is one way to potentially reduce costs.

This research was part of a study aimed at detection and treatment of AHI in an urban population of predominantly gay men and other men who have sex with men in Bangkok. Samples that tested negative on fourth generation immunoassay were pooled (median pool size was 14 samples) before undergoing HIV RNA testing. Some 31 pools were positive (0.5% of pools tested) and one positive specimen was then identified from each of those pools. Overall, this constituted only around a quarter of all AHI cases detected. The remainder were defined as AHI on the basis of positive fourth generation but negative second and third generation antibody tests. Individuals detected only by HIV RNA had somewhat lower viral loads than people detected by immunoassay. Follow-up testing illustrated that this was a time when viral load was increasing rapidly. This highlights the potential impact that detection and treatment at this stage could have on reducing onward transmission.

Although interpretation of the study is somewhat complicated by the use of several different assays during the study and complicated algorithms to define outcomes, the basic message seems clear. Fourth generation immunoassays may detect the majority of acute infections. But there may still be a role for pooled HIV RNA testing in certain key populations to maximize detection of AHI. This study was not really designed to evaluate the real world impact of the testing strategy, as follow-up was very tightly controlled and almost all people initiated ART within one week. Although there was some basic costing analysis included, more detailed cost-effectiveness studies will be important to understand whether or not pooled HIV RNA testing has a role in routine practice.

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Community-based rapid testing boosts case finding among MSM in China

Case finding advantage of HIV rapid tests in community settings: men who have sex with men in 12 programme areas in China, 2011.

Zhang D, Qi J, Fu X, Meng S, Li C, Sun J. Int J STD AIDS. 2015 May;26(6):402-13. doi: 10.1177/0956462414542986. Epub 2014 Jul 15.

We sought to describe the advantage of rapid tests over ELISA tests in community-based screening for HIV among men who have sex with men (MSM) in urban areas of China. Data of 31 406 screening tests conducted over six months in 2011 among MSM across 12 areas were analyzed to compare the differences between those receiving rapid testing and ELISA. Rapid tests accounted for 45.8% of these screening tests. The rate of being screened positive was 7.2% among rapid tests and 5.3% for ELISA tests (X(2)= 49.161, p < 0.001). This advantage of rapid test in HIV case finding persisted even when socio-demographic, behavioural, screening recruitment channel and city were controlled for in logistic regression (exp[beta] = 1.42, p < 0.001, 95% CI = 1.27,1.59). MSM who received rapid tests, compared with those tested by ELISA, were less likely to use condoms during last anal sex (50.8% vs. 72.3%, X(2)= 1706.146, p < 0.001), more likely to have multiple sex partners (55.7% vs. 49.5%, X(2)= 238.188, p < 0.001) and less likely to have previously undergone HIV testing (38.8% vs. 54.7%, X(2)= 798.476, p < 0.001). These results demonstrate the robustness of the advantage of rapid tests over traditional ELISA tests in screening for MSM with HIV infection in cooperation with community-based organizations in urban settings in China.

Abstract access

Editor’s notes: The prevalence of HIV among gay men and other men who have sex with men in China has increased from 1% to 5% between 2006 and 2011. The increase in prevalence has motivated the development of a new HIV testing strategy to reach this key population. The China-Gates HIV Programme facilitated partnerships between local government health departments with community-based organizations (CBO) to reach and offer rapid HIV screening tests to gay men and other men who have sex with men in 14 cities and one province. Between July and December 2011, 17 015 men were tested through established HIV testing sites (run solely by the health departments, which used enzyme-linked immunosorbent assay [ELISA] testing) and another 14 391 men were tested at sites which were established, promoted, and run by the government-CBO partnerships. These sites used rapid HIV tests, and referred to the health department for confirmatory testing. After controlling for sociodemographic characteristics, transmission risk factors and geographic location, the odds of testing positive for HIV was 42% higher for men who were screened at partnership sites. This partnership demonstrates an innovative, culturally appropriate and scale-able model. For key populations, partnerships of this nature can lead to earlier treatment initiation and a reduction in secondary transmission.

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Directly observed PrEP among people who inject drugs – useful for improving adherence?

The impact of adherence to preexposure prophylaxis on the risk of HIV infection among people who inject drugs.

Martin M, Vanichseni S, Suntharasamai P, Sangkum U, Mock PA, Leethochawalit M, Chiamwongpaet S, Curlin ME, Na-Pompet S, Warapronmongkholkul A, Kittimunkong S, Gvetadze RJ, McNicholl JM, Paxton LA, Choopanya K, Bangkok Tenofovir Study Group. AIDS. 2015 Apr 24;29(7):819-24. doi: 10.1097/QAD.0000000000000613.

Objective: To describe participant adherence to daily oral tenofovir in an HIV preexposure prophylaxis (PrEP) trial, examine factors associated with adherence, and assess the impact of adherence on the risk of HIV infection.

Design: The Bangkok Tenofovir Study was a randomized, double-blind, placebo-controlled trial conducted among people who inject drugs, 2005-2012.

Methods: Participants chose daily visits or monthly visits. Study nurses observed participants swallow study drug and both initialed a diary. We assessed adherence using the diary. We examined adherence by age group and sex and used logistic regression to evaluate demographics and risk behaviors as predictors of adherence and Cox regression to assess the impact of adherence on the risk of HIV infection.

Results: A total of 2413 people enrolled and contributed 9665 person-years of follow-up (mean 4.0 years, maximum 6.9 years). The risk of HIV infection decreased as adherence improved, from 48.9% overall to 83.5% for those with at least 97.5% adherence*. In multivariable analysis, men were less adherent than women (P = 0.006) and participants 20-29 years old (P < 0.001) and 30-39 years old (P = 0.01) were less adherent than older participants. Other factors associated with poor adherence included incarceration (P = 0.02) and injecting methamphetamine (P = 0.04).

Conclusion: In this HIV PrEP trial among people who inject drugs, improved adherence to daily tenofovir was associated with a lower risk of HIV infection. This is consistent with trials among MSM and HIV-discordant heterosexual couples and suggests that HIV PrEP can provide a high level of protection from HIV infection.

*The authors mean that effectiveness improved from 48.9% overall to 83.5% in those who were 97.5% adherent.

Abstract access 

Editor’s notes: Randomised controlled trials have illustrated that daily oral tenofovir as pre-exposure prophylaxis (PrEP) can reduce HIV transmission. In this study, using data from the only PrEP trial to be completed among people who inject drugs, the investigators assessed the impact of directly-observed adherence to PrEP on the incidence of HIV infection in the Bangkok Tenofovir Study. Adherence was defined as the proportion of days recorded in the participants’ diaries that the participant took the study drug.  On average, participants took the study drug on 84% of days. Their findings of a strong association of increasing levels of adherence with reduced risk of HIV infection add to existing literature on the importance of adherence for PrEP effectiveness among gay men and other men who have sex with men and HIV-discordant couples. The novelty of this study was to directly observe adherence to PrEP.  Directly observed ART treatment has been used in prisons and drug treatment centres, and the potential of this method to improve adherence estimation is interesting.

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Harnessing the successful political prioritisation of HIV to reduce the burden of congenital syphilis

Prevention of mother-to-child transmission of syphilis and HIV in China: What drives political prioritization and what can this tell us about promoting dual elimination?

Wu D, Hawkes S, Buse K. Int J Gynaecol Obstet. 2015 Apr 29. pii: S0020-7292(15)00202-7. doi: 10.1016/j.ijgo.2015.04.005. [Epub ahead of print]

Objective: The present study aims to identify reasons behind the lower political priority of mother-to-child transmission (MTCT) of syphilis compared with HIV, despite the former presenting a much larger and growing burden than the latter, in China, over the 20 years prior to 2010.

Methods: We undertook a comparative policy analysis, based on informant interviews and documentation review of control of MTCT of syphilis and HIV, as well as nonparticipant observation of relevant meetings/trainings to investigate agenda-setting prior to 2010.

Results: We identified several factors contributing to the lower priority accorded to MTCT of syphilis: relative neglect at a global level, dearth of international financial and technical support, poorly unified national policy community with weak accountability mechanisms, insufficient understanding of the epidemic and policy options, and a prevailing negative framing of syphilis that resulted in significant stigmatization.

Conclusion: A dual elimination goal will only be reached when prioritization of MTCT of syphilis is enhanced in both the international and national agendas.

Abstract  Full-text [free] access

Editor’s notes:  In 2009, China had nearly 11 000 reported cases of congenital syphilis, compared to 57 cases of mother-to-child HIV transmission, yet congenital syphilis was not a policy priority. The authors investigate and compare the policy responses to the two infections in order to understand the determinants of prioritisation in Chinese health policy. The national policy response to the mother-to-child transmission of HIV highlights the importance of global agendas. These include reporting mechanisms, international financial and technical assistance, credible indicators, as well as cohesive national policy communities that coalesce around a formal mechanism of coordination and policy influence, namely the Chinese National Centre for Women and Children’s Health. In addition, the specific national policy environment and other focusing events were critical to the prioritisation of the mother-to-child transmission of HIV. The new leadership was moving towards a socio-economic equality agenda, and the recent severe acute respiratory syndrome (SARS) outbreak had further underscored the importance of controlling infectious diseases. Alongside this, the national ‘blood selling’ scandal, during which hundreds of thousands of rural Chinese acquired HIV through blood selling in the 90s, was receiving increasing attention in international media. This contributed to a different framing of the HIV issue, away from the stigmatising ‘immoral’ narrative to an ‘innocent victims’ narrative. Congenital syphilis, unfortunately, continued to suffer from a stigmatising framing. However, delivery platforms for the effective prevention of mother-to-child transmission of HIV have been established and could be used for a dual control and elimination approach, with greater health benefits. The authors conclude that greater policy prioritisation could be achieved with a more nuanced framing of the two infections as being linked when it comes to underlying vulnerability and feasibility of solutions. It will require a strong partnership and collaboration between the mother-to-child transmission of syphilis and HIV policy communities.       

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Donor pull-out: how much will it cost to fill the gap for HIV testing in Viet Nam?

Expenditure analysis of HIV testing and counseling services using the cascade framework in Vietnam.

Nguyen VT, Nguyen HT, Nguyen QC, Duong PT, West G. PLoS One. 2015 May 15;10(5):e0126659. doi: 10.1371/journal.pone.0126659. eCollection 2015.

Objectives: Currently, HIV testing and counseling (HTC) services in Vietnam are primarily funded by international sources. However, international funders are now planning to withdraw their support and the Government of Vietnam (GVN) is seeking to identify domestic funding and generate client fees to continue services. A clear understanding of the cost to sustain current HTC services is becoming increasingly important to facilitate planning that can lead to making HTC and other HIV services more affordable and sustainable in Vietnam. The objectives of this analysis were to provide a snapshot of current program costs to achieve key program outcomes including 1) testing and identifying PLHIV unaware of their HIV status and 2) successfully enrolling HIV (+) clients in care.

Methods: We reviewed expenditure data reported by 34 HTC sites in nine Vietnamese provinces over a one-year period from October 2012 to September 2013. Data on program outcomes were extracted from the HTC database of 42 390 client records. Analysis was carried out from the service providers' perspective.

Results: The mean expenditure for a single client provided HTC services (testing, receiving results and referral for care/treatment) was US $7.6. The unit expenditure per PLHIV identified through these services varied widely from US $22.8 to $741.5 (median: $131.8). Excluding repeat tests, the range for expenditure to newly diagnose a PLHIV was even wider (from US $30.8 to $1483.0). The mean expenditure for one successfully referred HIV client to care services was US $466.6. Personnel costs contributed most to the total cost.

Conclusions: Our analysis found a wide range of expenditures by site for achieving the same outcomes. Re-designing systems to provide services at the lowest feasible cost is essential to making HIV services more affordable and treatment for prevention programs feasible in Vietnam. The analysis also found that understanding the determinants and reasons for variance in service costs by site is an important enhancement to the cascade of HIV services framework now adapted for and extensively used in Vietnam for planning and evaluation.

Abstract  Full-text [free] access

Editor’s notes: Some 91% of expenditure for HIV testing and counselling (HTC) in Viet Nam is funded by international donors. As donors start to reduce their contributions in the coming years, more of the costs will have to be fronted by the government of Viet Nam. Consequently, this paper looks at the cost around diagnosing HIV within the context of the care and treatment cascade, including not only the cost per person diagnosed, but also the cost of successfully enrolling people who have tested positive for HIV into care and treatment. This is particularly important in the context of Viet Nam, where only 29% of people estimated to be living with HIV have ever been enrolled in care and treatment services. 

An important finding of the paper is in the break-down of costs by input by facilities. The authors found that the cost of personnel account for 40% of total costs. More importantly, they also found that the personnel costs vary widely between facilities, which may suggest that some facilities are over-staffed and are not allocating tasks efficiently. This is a key finding. As financial resources become scarcer, savings may need to be found by determining the optimal level of staffing and task-shifting.

The paper illustrates, as is to be expected, that the cost per person successfully enrolled in care and treatment is substantially higher than the costs per person tested and per person testing positive.  However, it is not entirely clear whether the extra cost is explained simply by the fact that the overhead and start-up costs are allocated to a smaller number of people, or whether there are additional costs involved in a successful referral. This area needs further exploration. Additionally, an interesting follow-up to this paper could take on the costing from a societal perspective with the aim to understand the relation between patient-level costs and the successful link between testing and referral to care and treatment services.

Viet Nam
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Screening for and treating cryptococcal infection – better evidence of impact necessary

Cryptococcal antigen screening and early antifungal treatment to prevent cryptococcal meningitis: a review of the literature.

Kaplan JE, Vallabhaneni S, Smith RM, Chideya-Chihota S, Chehab J, Park B. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S331-9. doi: 10.1097/QAI.0000000000000484.

Background: Screening individuals with AIDS for serum cryptococcal antigen (CrAg), followed by treatment of CrAg positives with antifungals, may prevent cryptococcal meningitis. This review examined data on CrAg screening and treatment in resource-limited settings.

Methods: We searched articles published during 2007-2014 on the effectiveness and cost-effectiveness of CrAg screening and treatment on the outcomes of mortality, morbidity, retention in care, quality of life, and/or prevention of ongoing HIV transmission. We rated overall quality of individual articles, summarized the body of evidence, the expected impact, and cost-effectiveness for each outcome.

Results: We identified 2613 articles. Eight met all inclusion criteria. Five studies addressed mortality and/or morbidity outcomes; all were observational and had small sample sizes; 3 lacked a comparison group. Ratings of study quality ranged from "medium" to "weak," and the quality of the overall body of evidence for mortality and morbidity outcomes was rated as "fair." The intervention's expected impact on mortality and morbidity was rated as "moderate." The 4 cost-effectiveness studies included in the analysis showed that CrAg screening and treatment interventions are highly cost-effective. No studies addressed retention in care, quality of life, or HIV transmission.

Conclusions: Although limited, the body of evidence regarding CrAg screening and treatment suggests that the intervention may have an impact on preventing cryptococcal meningitis and death in persons with AIDS. Additional research is needed to quantify the intervention's effectiveness and identify optimal treatment dosing and implementation best practices.

Abstract access 

Editor’s notes: This systematic review was one of a series aimed at evaluating the impact of services supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR). The review set out to assess the evidence around the impact of targeted cryptococcal antigen (CrAg) testing and antifungal treatment for people with advanced HIV disease. In 2011 World Health Organization (WHO) gave a conditional recommendation, based on low quality evidence, that adults with CD4 count <100 cells per μL, in populations where the CrAg prevalence is above 3%, should undergo CrAg screening and be provided with antifungal treatment if CrAg positive.

The quality of the evidence was rated using a system adapted from the US Preventive Services Task Force. Five observational studies that evaluated the impact of the CrAg screening and antifungal treatment approach on mortality were included. Most of these did not have a comparator. One study used a historical control group from the same facility and another study compared mortality in people who received fluconazole following a positive CrAg, to people who did not. All studies had a very small number of deaths. In the five studies, mortality in people testing CrAg positive and receiving fluconazole varied between 0 and 29%. Based on these studies it would be difficult to evaluate the true impact of the strategy on mortality.

Four cost-effectiveness studies from different settings were also reviewed. All four studies suggested that a strategy with CrAg screening and antifungal treatment would be cost-effective. However, the cost-effectiveness modelling was based on data from the observational studies mentioned above and required other assumptions based on low quality evidence, leading to substantial uncertainty around the cost-effectiveness estimates.

Although a few countries have already implemented CrAg screening and antifungal treatment strategies, better quality evidence is necessary to inform management more broadly in countries with a high burden of cryptococcal disease. Some evidence has already appeared, with a randomised controlled trial in Tanzania and Zambia demonstrating a reduction in mortality with a CrAg screening strategy combined with a community support package during the early phase of antiretroviral therapy (see HIV This Month Issue 4). In addition there are three other randomised controlled trials exploring the impact of CrAg screening, ongoing or planned in Uganda, Zimbabwe and Viet Nam (NCT01535469, NCT02434172, and NCT02334670). It is hoped that the evidence generated by these studies will improve our understanding of the impact of a CrAg screening strategy and also give further insight into how best to implement this in different health care settings.   

Avoid TB deaths
Africa, Asia
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Economic strengthening programmes for people living with HIV may increase their quality of life

The impact of social services interventions in developing countries: a review of the evidence of impact on clinical outcomes in people living with HIV.

Bateganya MH, Dong M, Oguntomilade J, Suraratdecha C. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S357-67. doi: 10.1097/QAI.0000000000000498.

Background: Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions-economic strengthening and legal services-on key health outcomes has not been appraised.

Methods: We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness.

Results: Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes.

Conclusions: Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

Abstract access 

Editor’s notes: To mitigate the impact of HIV on people living with HIV and their households, economic strengthening programmes and legal services have often been implemented. However, few have been rigorously evaluated in terms of their impact on HIV outcomes. This review of the literature reveals a limited and weak evidence base on the impact of such social services programmes for people living with HIV on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission. It only identifies eight studies, all of them on economic strengthening activities, and most of them qualitative or observational in design. The authors conclude that the evidence suggests a high impact of such programmes on the quality of life for people living with HIV, which was consistently reported in the studies identified. Access to other confounding services, such as ART and broader community-based support, requires these findings to be interpreted with caution.     

The study clearly highlights the need for more rigorous impact and economic evaluations in this area. Indeed, the review did not identify any studies considering costs or cost-effectiveness. The authors also recommend more research into the feasibility and sustainability of these programmes, as well as greater focus of the implemented programmes on population groups in the greatest need.  

Africa, Asia, Latin America
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Need for further water, sanitation and hygiene programmes among people living with HIV

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review.

Yates T, Lantagne D, Mintz E, Quick R. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S318-30. doi: 10.1097/QAI.0000000000000487.

Background: Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

Methods: We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

Results: We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

Conclusions: Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

Abstract access 

Editor’s notes: Researchers, implementers, and policy makers have been examining how to better integrate programmes with overlapping burdens of morbidity and mortality. This paper illustrates how access to clean water and good sanitation practices, or lack thereof, can impact the health of people living with HIV. Water, sanitation, and hygiene (WASH) programmes can improve the negative effects poor water quality and bad sanitation have on people living with HIV. They reduce or even eliminate diarrheal infections, which allow for better absorption of HIV treatment medication that leads to a reduction in viral load and increased CD4 counts. While this systematic review revealed evidence on the reduced burden of morbidity that WASH programmes can confer, little has been done in the way of research linking WASH programmes to mortality in people living with HIV, nor how they may affect adherence or retention in care. Side effects of HIV treatment is a common reason why people stop taking medications, and common side effects are nausea and diarrhoea. It is possible that intestinal issues caused by unsafe drinking water could exacerbate the impact of side effects on people already experiencing them, therefore reducing motivation to continue taking their ARVs. This paper also suggests that synergies in cost sharing and increasing cost effectiveness could be achieved by integrating programmes. However further research is necessary to fully understand the logistical and cost implications.


Africa, Asia
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Re-focusing the response in Niger – a greater need for sex worker programmes?

Reorienting the HIV response in Niger toward sex work interventions: from better evidence to targeted and expanded practice. 

Fraser N, Kerr CC, Harouna Z, Alhousseini Z, Cheikh N, Gray R, Shattock A, Wilson DP, Haacker M, Shubber Z, Masaki E, Karamoko D, Görgens M. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S213-20. doi: 10.1097/QAI.0000000000000456.

Background: Niger's low-burden, sex-work-driven HIV epidemic is situated in a context of high economic and demographic growth. Resource availability of HIV/AIDS has been decreasing recently. In 2007-2012, only 1% of HIV expenditure was for sex work interventions, but an estimated 37% of HIV incidence was directly linked to sex work in 2012. The Government of Niger requested assistance to determine an efficient allocation of its HIV resources and to strengthen HIV programming for sex workers. 

Methods: Optima, an integrated epidemiologic and optimization tool, was applied using local HIV epidemic, demographic, programmatic, expenditure, and cost data. A mathematical optimization algorithm was used to determine the best resource allocation for minimizing HIV incidence and disability-adjusted life years (DALYs) over 10 years. 

Results: Efficient allocation of the available HIV resources, to minimize incidence and DALYs, would increase expenditure for sex work interventions from 1% to 4%-5%, almost double expenditure for antiretroviral treatment and for the prevention of mother-to-child transmission, and reduce expenditure for HIV programs focusing on the general population. Such an investment could prevent an additional 12% of new infections despite a budget of less than half of the 2012 reference year. Most averted infections would arise from increased funding for sex work interventions. 

Conclusions: This allocative efficiency analysis makes the case for increased investment in sex work interventions to minimize future HIV incidence and DALYs. Optimal HIV resource allocation combined with improved program implementation could have even greater HIV impact. Technical assistance is being provided to make the money invested in sex work programs work better and help Niger to achieve a cost-effective and sustainable HIV response.

Abstract access  

Editor’s notes: Niger has a low-level HIV epidemic concentrated in key populations such as female sex workers, with prevalence levels of 17% in 2011. Only around 23% of female sex workers report using a condom at every sexual act, making them a highly vulnerable group. Additionally there are barriers to using the health centres such as service costs, and the geographic distance.

This article summarizes the HIV epidemic and response situation in Niger with a focus on female sex workers, including modelled trends using Optima. It then presents new evidence on different resource allocation scenarios and the projected impact on the HIV epidemic. Optima, a deterministic mathematical model for HIV optimization and prioritization, was applied to local epidemiologic, demographic, programmatic, expenditure, and cost data. 

The optimization function uses an algorithm to find the best allocation of resources to meet the objective of either minimizing HIV incidence or disability-adjusted life years (DALYs) until 2024. Contrary to the current approach of allocating 31% of spending to the general population and less than 1% to female sex workers, the Optima function advocates increased spending on antiretroviral therapy from 27% to 48%. Optima supports a focussed approach to reduce HIV incidence in female sex workers including mapping populations and a “programme intelligence” approach akin to that implemented in India and Nigeria.   

Africa, Asia
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Prevention services need to focus on newly-started sex workers in South India

Changes in HIV and syphilis prevalence among female sex workers from three serial crosssectional surveys in Karnataka state, South India. 

Isac S, Ramesh BM, Rajaram S, Washington R, Bradley JE, Reza-Paul S, Beattie TS, Alary M. BMJ Open. 2015 Mar 27;5(3):e007106. doi: 10.1136/bmjopen-2014-007106.

Objectives: This paper examined trends over time in condom use, and the prevalences of HIV and syphilis, among female sex workers (FSWs) in South India. 

Design: Data from three rounds of cross-sectional surveys were analysed, with HIV and high-titre syphilis prevalence as outcome variables. Multivariable analysis was applied to examine changes in prevalence over time. 

Setting: Five districts in Karnataka state, India. 

Participants: 7015 FSWs were interviewed over three rounds of surveys (round 1=2277; round 2=2387 and round 3=2351). Women who reported selling sex in exchange for money or gifts in the past month, and aged between 18 and 49 years, were included. 

Interventions: The surveys were conducted to monitor a targeted HIV prevention programme during 2004-2012. The main interventions included peer-led community outreach, services for the treatment and prevention of sexually transmitted infections, and empowering FSWs through community mobilisation.  

Results: HIV prevalence declined significantly from rounds 1 to 3, from 19.6% to 10.8%

(adjusted OR (AOR)=0.48, p<0.001); high-titre syphilis prevalence declined from 5.9% to 2.4% (AOR=0.50, p<0.001). Reductions were observed in most substrata of FSWs, although reductions among new sex workers, and those soliciting clients using mobile phones or from home, were not statistically significant. Condom use 'always' with occasional clients increased from 73% to 91% (AOR=1.9, p<0.001), with repeat clients from 52% to 86% (AOR=5.0, p<0.001) and with regular partners from 12% to 30% (AOR=4.2, p<0.001). Increased condom use was associated with exposure to the programme. However, condom use with regular partners remained low. 

Conclusions: The prevalences of HIV infection and high-titre syphilis among FSWs have steadily declined with increased condom use. Further reductions in prevalence will require intensification of prevention efforts for new FSWs and those soliciting clients using mobile phones or from home, as well as increasing condom use in the context of regular partnerships.

Abstract   Full-text [free] access

Editor’s notes: The HIV epidemic in India has remained largely concentrated in key populations, particularly among female sex workers. One of the most high profile HIV prevention efforts in India has been the Avahan AIDS initiative, which in Karnataka State has reached over 60 000 female sex workers since 2004. The initiative involves peer-mediated safer sex communications, intensive management of sexually transmitted infections, and facilitation of safer sex environments. In the final round of a repeat cross-sectional survey conducted between 2004 and 2011, investigators found that nearly all female sex workers were contacted by a peer educator, had seen a condom demonstration, or had visited a programme clinic. In that time, the prevalence of HIV fell from 19.6% to 10.8% (P<0.01) and the prevalence of new syphilis infections fell from 5.9% to 2.4% (P<0.01). However, HIV prevalence among new female sex workers remained high, reflecting the challenges in reaching women starting sex work before they become HIV positive. The programme is notable for its responsiveness to the HIV prevention needs of female sex workers and the current paper confirms continued increases in condom use and preventive services. However, with the changing nature of sex work, current challenges include preventive services for women soliciting sex through mobile phones, and reaching sex workers soon after they start sex work. 

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